Focusing on acute MI in women

Cardiovascular disease affects both men and women, but women tend to have more atypical
symptoms of acute myocardial infarction (MI). Physicians need to understand these
potential differences in presentation in order to improve outcomes, according to the
first scientific statement on the topic from the American Heart Association (AHA),
published online on Jan. 25 by Circulation. ACP Hospitalist spoke with lead author Laxmi S. Mehta, MD, the director of the women's cardiovascular
health program and an associate professor of medicine at the Ohio State University
Wexner Medical Center in Columbus.

Q: What are some of the key differences in symptom presentation between men and women
that hospitalists should know?

A: When we think of MI, we frequently think of a substernal chest pressure that's radiating
down the left arm, associated with some shortness of breath and diaphoresis. While
women can have atypical symptoms, they still could present the same way as men with
all those [classic] symptoms. Chest pain can be atypical in women and can be chest
pressure, sharp pain, pleuritic pain, or reproducible kind of pain, and it doesn't
necessarily need to be left-sided. If women present with chest pain, but it doesn't
sound quite like the classic symptoms and it's new for them, then I think it warrants
further investigation and, at bare minimum, an EKG if presenting with acute symptoms.
Women might not even have chest pain—they could have shoulder pain or intense
fatigue, generalized weakness, flu-like symptoms, back pain, indigestion, palpitations.
Many women experience atypical symptoms, which can make diagnosis a challenge. Questioning
how acute the symptoms are and if the symptoms change with exertion is a helpful tool
in gauging if it's something potentially related to the heart.

Q: How might that differ from past approaches?

A: In the past, women were being undertreated, there were delays in women presenting
to the hospital, and then physician and nursing staff underdiagnosed women with heart
attacks. Nowadays, a lot of hospitals end up doing EKGs on anyone with a symptom from
the waist up, so at least we can capture major heart attacks if they're occurring.
But the atypical symptoms or nature of those symptoms can really be perplexing and
can certainly lead you down a pathway that might not be heart-related.

Q: The paper notes some racial and ethnic differences in women's presentation and risk
factors, as well as higher mortality among younger women (about 45 to 55 years) compared
to older women. What should hospitalists keep in mind when treating women who fit
into these categories?

A: Minority populations have several risk factors [e.g., more comorbidities such as diabetes,
hypertension, heart failure, and obesity] at the time of presentation with [acute]
MI, so paying attention to those risk factors and managing those risk factors is going
to be key. Paying attention to some of the psychosocial issues that go along with
being younger or being a racial minority with heart disease is also important. That's
where a team-based approach is imperative.

It's perplexing why the mortality rates are higher in younger women, and there's a
lot more to learn. In younger women with MI, what happens is they tend to have a lot
of competing roles, especially if they're young and still have children at home, and
that can sometimes be a burden on them taking care of themselves or continuing cardiac
rehabilitation or some of the other necessary [treatments]. Many of the young women
who present with heart attacks are smokers, so working really hard to engage them
to quit the smoking and looking at what kind of hormonal replacement or birth control
pills they're on is going to be key. Diabetics and especially diabetic women can present
at a younger age, so modifying diabetes and having tight glucose control is imperative,
as well.

Q: What do we know about the proper course of treatment for women with acute MI? Does
it differ from male patients?

A: What we know about treatment is based on research. However, women have only comprised
25% to 30% of the cohort in research studies, so they are a minority. We've taken
what we've learned from the research predominately in men and have [applied] it to
women and said, ‘That's the treatment.’ From the data we have, we're
still recommending similar treatment in terms of aspirin, beta-blockers, [angiotensin-converting
enzyme] inhibitors, and statins, and we're still recommending cardiac catheterizations.
Women continue to have twice the bleeding rates as men. Some of it is related to their
body weight, kidney function, and adjustment of dosing guidelines. If anticoagulants
are given, we do recommend some titration of doses based on weight because in the
past, [clinicians] weren't taking weight [into account], and women are smaller.

What we see, though, is that women are still under-referred for some of these pharmacologic
treatments in hospital, at discharge, and after discharge. Some of that is due to
provider bias of not getting those patients on the medications, some of that is also
due to patients' nonadherence to taking medications or refusal to take the medications.
We also know that women who have nonobstructive coronary heart disease are less likely
to be treated with medications compared to those who have obstructive disease. That's
where some of the disparities occur in outcomes. An important part of the treatment
of MI besides revascularization and medications is cardiac rehabilitation. Women are
under-referred for cardiac rehabilitation. Even if they are referred, their attendance
rates of going to cardiac rehabilitation are poor compared to men, despite it being
an important treatment. Additionally, women suffer from more depression than men at
baseline and after a cardiac event, so working on depression management is going to
be imperative for the recovery of the patient's health.

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